Medicare’s ETC Model showed no clear improvement in timely transplant access

Medicare’s End-Stage Renal Disease Treatment Choices (ETC) Model, introduced in 2021, assigned 30% of US dialysis facilities to financial incentives intended to increase home dialysis, transplant waitlisting, and living-donor transplantation. Researchers used linked registry and administrative data to compare adult Traditional Medicare beneficiaries starting dialysis at ETC and control facilities in Georgia, North Carolina, and South Carolina. The difference-in-differences analysis included 26,809 people at 706 facilities, comparing 2015–2019 with 2021–2023.

The study assessed referral within one year of dialysis initiation, evaluation initiation within six months of referral, and waitlisting or living-donor transplantation within two years. Adjusted differential increases associated with ETC implementation were 3.58 percentage points for timely referral (95% CI, −1.30 to 8.45), 8.52 points for evaluation initiation (95% CI, −1.42 to 18.45), and 3.61 points for waitlisting or living-donor transplantation (95% CI, −0.26 to 7.48). All confidence intervals included no difference; time-to-event analyses were consistent.

The results provide no definitive evidence that the model improved these access measures in the three states. COVID-era delays in referral affected both groups, and findings may not generalize beyond the study population and region. The authors conclude that incentive misalignment alone is unlikely to explain the model’s limited impact on transplantation.